Avir At Rose Trail
Avir at Rose Trail in TYLER, TX — inspection on August 15, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Record review of the Resident #1's monitoring log dated 8/10/25 indicated Resident #1 was on one-to-one monitoring beginning 8/10/25 at 7:00 p.m. and continued until 8/11/25 at 11:00 a.m when she was transferred to a memory care unit at another facility.
Record review of in-services dated 8/11/25 indicated all active staff were in-serviced regarding wandering and elopement, safety and supervision of residents, missing persons policy and procedure, and alarmed entrance and exit doors and the new door monitoring log policy.
Staff interviewed (LVN A, LVN B, LVN C, RN D, RN E, CNA F, CNA G, CNA H, and CNA J) on 8/13/25 between 11:00 a.m. and 4:07 p.m. were able to articulate the content of the new door log book policy, and what to do in the event of an elopement.
Staff interviewed said that they would notify the charge nurse and attempt to redirect the resident if they saw someone attempting to elope from the facility.
Investigator ensured all exits armed with Wanderguard system were in working order by approaching each exit with a Wanderguard device and hearing the alarm sound.
The noncompliance was identified as PNC IJ.
The noncompliance began on 8/10/2025 and ended on 8/11/2025.
The facility had corrected the noncompliance before the survey began.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Rose Trail Nursing and Rehabilitation Center
930 S Baxter Tyler, TX 75701
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 8/14/25 at 2:56 p.m. the Physician said he did not know about tracheostomies and did not want to give his medical opinion as he is not familiar with facility policy.
The Physician said the nurses should call emergency medical services in the event of an emergency and should be able to care for Resident #2 in the event of an emergency.
The Physician said the surveyor should talk to a respiratory therapist regarding the importance of having necessary supplies in the facility for tracheostomy treatment as he was not sure of the facility policy.
During an interview on 8/15/25 at 9:45 a.m. the RT said the facility should have in the emergency tracheostomy kit at bedside a tracheostomy tubes the same size and one size smaller than what the resident has inserted, an ambu bag, and a suction catheter.
The RT said most of the time in the event of decannulation a tracheostomy tubes the same size was not able to be re-inserted and a tracheostomy tube one size smaller was required.
The RT said in the event of a life-or-death emergency a tracheostomy tube one size smaller that the sterile packaging had been opened on could be used.
The RT said most tracheostomy patients were able to breath without the tracheostomy unless it was a brand-new tracheostomy.
Record review of the facility's Tracheostomy Care policy dated 2001 indicated, The purpose of this procedure is to guide tracheostomy care ant the cleaning of reusable tracheostomy cannulas.A replacement tracheostomy tube must be available at the bedside at all times.
Facility ID: